157204130-4-5-2021-24-NP-MHON-C3SMBK-20210608092800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157204130
Report Date: 03/31/2021
Date Signed: 04/05/2021 07:48:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2021 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20210322140606

FACILITY NAME:	PACIFICA SENIOR LIVING BAKERSFIELD		FACILITY NUMBER:	157204130
ADMINISTRATOR:	BRADFORD, CASSONDRA		FACILITY TYPE:	740
ADDRESS:	3209 BOOKSIDE DR		TELEPHONE:	(661) 663-9671
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	55	CENSUS: 39	DATE:	03/31/2021
		ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Executive Director (ED), Cassondra Bradford		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Facility did not release resident's records to authorized representative.

INVESTIGATION FINDINGS:

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On 03/31/2021, Licesning Program Analyst (LPA) L Salazar arrived at the facility to obtain Resident R1's facility file. LPA spoke to ED regarding the allegation and requested R1's facility file. Per California Code of Regulation (CCR) Title 22, Division 6, 87506. LPA obtained resident file for copying from Office Manager, Melissa. LPA left a signed record release form at the facility and retained one copy for records. LPA will return file on 04/05/2021.

Based on LPAs interview conducted with ED, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Health and Safety Code §1569.269(21) is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 03/31/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210322140606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PACIFICA SENIOR LIVING BAKERSFIELD	FACILITY NUMBER: 157204130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/31/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2021 Section Cited HSC 1569.269(21)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (21)To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidence by interview with ED stating the requested resident records were archived and awaiting to be sent by Pacifica’s corporate office. The time required to produce records was exceeded.	1 2 3 4 5 6 7	ED produced records to LPA upon request. ED will coordinate with corporate office regarding follow through on deadline for resident records.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 03/31/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

LIC9099 (FAS) - (06/04)

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